First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

Postal code *

What type of services are you seeking?

How would you like to receive services? *

In-Person Only

Telehealth Only

Open to Both

Briefly describe the issue you would like to work on. *

Would you like first availability or work with a specific clinician? *

What's the best way to contact you?

How did you hear about us?

Email and SMS Text Message Risk Acknowledgement and Use Consent

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Resilience Therapy LCSW, PLLC therapists, providers, and/or office staff communicating with me via email or text message